Life is Precious: Views of Adolescents and their Mothers on Methods to Reduce Suicidal Behavior in Latinas

Abstract

Life is Precious (LIP) was developed to help reduce suicidal behavior in Latina adolescents. As part of an external evaluation of the LIP program, we conducted focus groups with adolescent participants and mothers, to learn whether participants and families believe that the activities of LIP address risks for suicidal behavior. Four focus groups were conducted: three with Latina adolescent LIP participants (n=31) and one with mothers (n=8). Transcripts were analyzed using ATLAS.ti. A grounded theory approach was used to identify themes and sub-themes. The following themes emerged: 1) Challenges contributing to suicidal behavior and self-harm among Latina adolescents; 2) How respondents believe that LIP is helping to reduce suicidal behavior; and 3) Ongoing challenges. Participants say that the LIP program helps adolescents feel better, and improve social relationships, academic performance, and relationships with their family. School nurses may wish to identify community-based programs offering similar services.

Latina adolescent girls in the United States have high rates of suicidal ideation and attempts; this phenomenon has been documented since the early 1990s (Baumann, Kuhlberg, & Zayas, 2010; Eaton et al., 2011) and across many countries of origin or heritage (e.g. Mexican, Puerto Rican, Dominican) (Zayas, Gulbas, Fedoraviciuis, & Cabassa, 2010). While Latino males ages 12–18 in the United States have twice the rate of completed suicide as Latina females (5.2 vs 2.76 per 100,000, chisq (1)=28, p<0.01) (CDC, 2015a), Latinas have higher rates of suicidal ideation and attempts than their male Latino counterparts: nationwide, 26% of Latina girls in grades 9–12 reported seriously considering suicide in the past year and 15% reported having attempted suicide in the past year, compared with 12% and 8% respectively for boys (p<0.01 for both) (CDC, 2015b).

Numerous risk factors for suicidal ideation and attempts have been identified for Latina adolescents; many are not unique to Latinas. Latina teens may face concerns with self-esteem (Zayas & Pilat, 2008), school performance, peer relationships (Goldston et al., 2008; Alonzo, Conway, & Modrek, 2016; Price and Khubchandani, 2017), living in poverty (Zayas et al., 2010) and substance use (Eaton et al., 2011); these factors may be associated with depressive symptoms and suicidal ideation for many adolescents.

However, in addition to these risk factors, Latina adolescents in the United States face additional risk factors for suicidal ideation and attempts. Many Latina teens face adolescent development milestones while bridging two cultures: a U.S. culture that tends to emphasize independence and academic achievement and a Latino culture that tends to emphasize a strong alliance and obligation to the family (known as familism) (Sabogal, Marin, Otero-Sabogal, Marin, & Perez-Stable, 1987) and more traditional gender roles (Zayas & Pilat, 2008). The conflict between the “pull of the connection to the family and its cultural traditions and the counter-pull of the adolescent’s need for increased autonomy” (Zayas & Pilat, 2008, p. 335) can lead to psychological conflicts for the adolescent and tension within the family, increasing the risk of depressive symptoms and suicidal ideation and attempts.

Previous quantitative and qualitative research has demonstrated that these risk factors have led to higher rates of suicidal ideation and attempts for Latina adolescents. Latina adolescents who are at higher risk for suicidal ideation report acculturating to U.S. culture faster than their parents (Cervantes, Goldbach, Varela, & Santisteban, 2014). This is further illustrated by the fact that second-generation Latinas (those who were born in the US) have greater risk of suicidal thoughts and attempts than first-generation immigrants (Zayas & Pilat, 2008). Other identified risk factors include having differing aspirations from their parents or feeling disconnected from their families (Gulbas, Hausmann-Stabile, De Luca, Tyler, & Zayas, 2015; Gulbas & Zayas, 2015), or not having parents who were interested in their academic achievement (Piña-Watson, Castillo, Rodriguez, & Ray, 2014).

Few Evidence-Based Treatment Options

To date, relatively little is known about how to address suicidal behavior in Latina adolescents. No treatments on the current suicide prevention best practices registries are specifically targeted to the unique needs of this population (Suicide Prevention Resource Center, 2017). One school-based program operating in two Minnesota schools, Project Wings, is specifically targeted to Latinas and offers a series of activities to help students cope with stress; feasibility trials have found reduced stress and depression among participants (Garcia, Pintor, Vazquez, & Alvarez-Zumarraga, 2013).

Life is Precious Program Design

Life is Precious (LIP) is a community-based program designed specifically to help Latina teens reduce suicidal behavior by addressing the multi-faceted risk factors faced by this population. LIP was developed at Comunilife, Inc., a social service and clinical agency founded and directed by Dr. Rosa M. Gil. The operation of LIP has been previously reported (Humensky et al., 2013; Humensky, Coronel, Gil, Mazzula, & Lewis-Fernández, 2016). LIP operates as an after-school program on weekdays and on Saturday mornings for Latinas age 12–18. The program operates three locations in New York City (Bronx, Brooklyn, and Queens) with independent office space within an outpatient mental health treatment center (Bronx) or stand-alone rented office space (Brooklyn and Queens). The programs do not have an identified catchment area, and accept participants from numerous schools and neighborhoods. Referrals come from outpatient mental health clinics, schools, hospitals, and from Latinas themselves and their families (Humensky et al., 2013). All participants have been identified as at risk of suicidal behavior, either as a result of a recent suicide attempt, current suicidal ideation, and/or the judgement of a clinician that the person is at risk of suicidal behavior.

The person must be receiving mental health treatment throughout their participation in LIP, either at a Comunilife outpatient mental health clinic or at another clinic. Thus, the program operates as a supplement to ongoing mental health treatment, by providing an additional set of services. LIP is staffed by bilingual counselors and social workers, who provide supportive services, including supported education (assisting participants in pursuing school) and family support (providing counseling between parents and adolescents, conflict management skills, and other support services to help improve the relationship between the parents and adolescents). While participating in the program, participants can complete homework, use the computer lab, participate in creative expression (art, music, or dance therapy with licensed therapists) and participate in the Healthy Initiative (shopping, planning and preparing healthy meals, and exercising). Families are invited to participate in LIP activities, but only the Latina adolescents are enrolled program participants. A conceptual model that describes how the program components were designed to address suicidal ideation and behavior is described in (Humensky et al., 2013). A program manual, fidelity assessment, and training materials are publicly available (CECC, 2017).

Evaluation Strategy

Comunilife partnered with the New York State Psychiatric Institute Center of Excellence for Cultural Competence to evaluate the LIP program. The goal of the evaluation was to determine whether LIP is meeting the needs of the Latina adolescents it serves and their families. In our pilot evaluation, we found that there were no attempted or completed suicides by LIP participants to date, and suicidal ideation, depressive symptoms, anger, and posttraumatic stress decreased significantly during program participation (Humensky, Coronel, Gil, Mazzula, & Lewis-Fernández, 2016). Additionally, as part of this evaluation, we conducted three focus groups with adolescent participants, and one focus group with mothers of participants to learn their views on preventing suicidal behavior, and whether participants and families believe that the activities of LIP address risk factors for suicidal behavior and contribute to improvements in health and quality of life. This report focuses on the focus group findings.

Methods

The New York State Psychiatric Institute Institutional Review Board (IRB) approved this study. Focus groups were conducted between December, 2013 and August, 2014. Participants were recruited via flyers placed in the LIP offices. Each focus group lasted 60–90 minutes and was held in a private room at an LIP office; no LIP staff was present during the sessions. At the time of the focus group recruitment, 107 adolescents had participated in the LIP intervention (Humensky, Coronel, Gil, Mazzula & Lewis-Fernández, 2016). A subset of these adolescents participated in these focus groups; a total of 31 adolescents participated in the three focus groups, which ranged in size from 6–14 participants (Krueger & Casey, 2000). The adolescent focus groups were conducted in English, as nearly all LIP participants are fluent in English (Humensky et al., 2013). Two of the three adolescent focus groups were co-led by a bilingual facilitator, and instant linguistic interpretation was done by the bilingual facilitator or other participants when a participant needed help with an English word or phrase.

Additionally, in order to determine whether the parents’ assessment of the quality of the program was similar or different to that of the adolescent participants, a separate focus group was conducted with parents (all who attended were mothers). Eight mothers participated in the parent focus group, which was conducted in Spanish by a bilingual clinician.

Adolescents were required to have a signed permission form from a parent in order to participate; these were made available at LIP offices the week before the focus group. On the day of the focus group, the respondents provided the signed permission form and signed their own assent forms. The mothers participating in the parent focus group signed informed consent forms. Persons were not required to participate in the focus groups and instead, could participate in alternate LIP activities at those times. The focus groups were open to any LIP participant (or parent of LIP participant) who wished to participate. In order to minimize the personal health information collected in focus groups, demographic information on participants was not collected.

Focus group discussion guides were developed after a comprehensive review of the literature to identify risk factors facing Latina adolescents and the ways in which LIP could help reduce suicidal behavior. Discussion guides covered the topics to be discussed, including what motivated the adolescent to join LIP; whether the program helped her reduce her suicidal behavior, and if so, how; and if the program did not help, the reasons why it was not helpful. Protocols were reviewed by two experts in qualitative research in Latino populations. At the end of the group, participants were invited to share anything else that they wished to discuss, and were also invited to approach the focus group moderators directly to share anything they did not wish to share with the group.

All interviews were audio-recorded and professionally transcribed; because the parent focus group was conducted in Spanish, the transcript was professionally translated into English and reviewed by a bilingual focus group moderator for accuracy prior to analysis. All transcriptions were uploaded to ATLAS.ti qualitative analysis software. A grounded theory approach guided the analysis (Padgett, 1998; Creswell, 2003; Ennis, Rios-Vargar, & Albert, 2011). The principal investigator (JH) and a research assistant (SD) independently reviewed transcripts and developed an open coding schema based on a priori and emerging themes. Each code condenses the data into analyzable units ranging from phases to paragraphs. To establish coding reliability, the principal investigator and research assistant each independently coded one pilot interview. They then met to review definitions and assignment of codes. The Cohen’s kappa indicated inter-rater agreement of 0.83 and so, they independently coded the four focus group transcripts (each coding two transcripts). Additional analyses include identification of sub-themes and descriptions of the range and salience of themes.

Results

All adolescent participants in the focus groups are LIP participants ages 12–18, and all of the parents who participated were mothers of girls who attend LIP. We did not track whether the mothers who participated also had daughters who participated in the focus groups; all focus groups were held on different days.

The following overall themes emerged: 1) Challenges contributing to suicidal behavior and self-harm among Latina adolescents; 2) How LIP is helping to reduce suicidal behavior; and 3) Ongoing challenges. Within those themes, several sub-themes emerged. Respondents identified challenges contributing to suicidal behavior and self-harm, including negative feelings, such as low self-esteem; family conflicts, including concerns resulting from issues of immigration, acculturation, and gender roles; and struggles in school and with peer relationships. Respondents identified various ways in which LIP helps to address suicidal behavior, including helping the girls feel better; being a “safe haven” to get away from other stressors; improving relationships with families and peers; providing support for the families in addition to the adolescents; and helping the participants to improve academic performance. A few ongoing challenges were noted, namely availability of activities and addressing participants’ relationships with staff when staff leave the program.

Challenges contributing to suicidal behavior and self-harm among Latina adolescents

Low self-esteem and other negative feelings leading to suicidal thoughts

Participants in the mothers’ and daughters’ focus groups identified negative feelings that they felt led to suicidal ideation and attempts, including low self-esteem, feeling isolated and alone, and depression. One girl stated, “Sometimes the feelings you get is like, low self-esteem, Or like you feel nobody’s listening, like what you say don’t matter.” Others related other negative life events. One girl discussed having been raped in the past, which she said led to suicidal thoughts. Another girl stated that her mother had abandoned her to be raised by her father, and this loss led to negative self-worth and suicidal feelings.

Family conflicts

Participants identified family conflicts, which stemmed from issues surrounding immigration, acculturation into U.S. society, and conflicts over gender roles. One mother noted that she moved to the U.S. and left her daughter in her home country with other relatives for several years. By the time her daughter was able to join her in New York, a chasm had opened in their relationship, making it difficult for them to communicate. Another mother noted that her daughter refuses to speak Spanish to her, and since she speaks no English, a younger sibling is required to interpret all communication. This obviously leads to limited communication with her older daughter. Participants noted that conflicts over gender roles and double standards (where sons are allowed greater independence than daughters) lead to fights and conflicts within the home. One participant noted “I have a younger brother. And he’s allowed to go out. He’s allowed to come home, like, whatever. And I’m not even allowed to go to school by myself.” Another noted, “I think if I was a boy, I wouldn’t be arguing with my mom so much.”

Academic and peer struggles

Participants described troubles in school or academics. One described a downward spiral: not feeling well led to missing school, which in turn led to poor grades and lower self-esteem.

I have problems sometimes with my grades, because when I’m sad I don’t go to school. To be honest with you, when I’m sad I’ll be like ‘f’ this, I’m not going to school, and I cut school. So then when I try to come back, it’s like I have to catch up on all that work, because I miss weeks of school, like it’s not one day. I miss weeks of not going, and then I have to catch up and all of that.

Both mothers and daughters described bullying that girls experience at school, and how it can influence self-esteem and academic performance. One mother noted:

And sometimes it’s also bullying that gives them that, because I had that problem with my daughter last year. So she, every day, in the beginning she used to like going to school. She never missed…And then later I saw that she didn’t want to go and it was because a lot of children were bothering her.

Participants noted that they feared bullying or name-calling if other students at school learned that they receive mental health treatment or have attempted suicide. One said she has been called “emo” (a term used in a derogatory way to describe someone who is moody and unhappy) and another described being called a “suicidal freak.” One said that she felt that other students saw her “differently” after learning that she was receiving therapy. Another felt that other students seemed to think that her suicidal behavior would be contagious or “rub off on them” if they continued to associate with her.

Many noted that they do not tell anyone at school that they go to LIP, to avoid stigma associated with suicidal behavior and using therapy. While some said that they will tell one or a few trusted friends, most said that they endeavor to keep LIP a secret. Most said that they don’t encounter other LIP participants at school, and if they do, they don’t let others know about their association with LIP. Their responses below, while delivered with humor, illustrate their strong beliefs about their need to keep their LIP participation a secret from their friends.

[Interviewer: Do your friends at school know you come to LIP?] [Multiple participants spoke up at once.] “Nope.” “Hell, no!” “Hell, no!”

[Interviewer: Do your friends know you come to LIP?] “I lie through my teeth. [quoting herself talking to her friends] ‘Oh, I have music class. I have work.’ That’s why I’m here. Yeah. [Laughing] You know, I don’t even tell them I have a therapist or a psychiatrist or none of that. No. No, no, no, no [more laughing].”

Respondents also noted that school officials can also contribute to a difficult environment, and continue the stigma, if they know about mental health treatment received by students. One respondent said, “I’ve met people who try to confide in their teachers. And things just started getting worse.” However, others found that their guidance counselors were supportive of their participation in LIP. One participant said, “I actually told my guidance counselor, because she noticed great improvement. And she just wanted to know, like, what I was doing.”

How LIP helps address the causes of suicidal behavior

LIP offers skills and resources to address negative feelings that contribute to suicidal behavior and self-harm

Many participants said that LIP’s environment of acceptance and “non-judging” led to them feeling peaceful when they are there. Several described it as a “safe haven” where they can have “peace and quiet” and get away from high-conflict homes and other stressors in their lives. Participants also reported feeling accepted by others who have also experienced similar struggles, “It’s nice to know that you are not the only one who has these problems.” Mothers also noted that the LIP staff tries to help the girls “feel special” and help them improve their self-esteem.

Several mothers described skills that their daughters have learned to combat negative emotions. Several mothers noted that their daughters would learn, instead of cutting themselves, to write “I love you” on their arms. The mothers said that the daughters continue to do this, and this practice has helped them reduce these self-harm behaviors.

Participants said that they like the opportunities for creative expression. One said she loves to write songs and learn to play guitar in the music program, “I just love the music.” Others like drawing, painting, and other types of artwork, such as collages. Mothers also said that they appreciate seeing the artwork their daughters create. One mother described a play that the girls put on for the mothers. In the play, the characters “killed violence,” which she saw as a window into her daughter’s thought process. “It was like they wanted to destroy the bad thoughts. And it was like a sign, but it was really nice.”

LIP helps families resolve conflicts

Participants described the skills that LIP therapists have taught them to address conflicts within the home. One participant said that she was taught to count to three before responding to a parent in anger, instead of yelling back and leaving the house. Two participants said that LIP has helped them understand their parents’ point of view during conflicts. One described learning to “be the bigger person” rather than responding in anger and “going down to their level” during conflicts. Another realized how other frustrations, such as with work, might be influencing the mother’s responses:

They tell me like if [my mother’s] saying something mean or something, maybe it’s because she had a bad day at work. And when you’re thinking about it, you’re like, yeah. She did come home from a long day of work and stuff. If that’s happening, you know, just try to like stay away for a while and let her calm down.

Several mothers reported that LIP’s activities have helped them bond. Trips, such as to Central Park, and activities, such as cooking, have given them positive shared experiences. One mother said, while she and her daughter have always had a difficult relationship, “in the kitchen, we communicated more.” Several daughters reported feeling closer to their mothers after participating in LIP. One participant said, “Sometimes people say like, ‘Oh you can’t trust a mom.’ But when you really look at it now, you can trust your mom. It depends which mother you have, so now I realize that.”

Several participants noted that LIP has helped them address some of the conflicts they feel with acculturation gaps between Latina culture and mainstream US society. Some said that they value spending time with other girls who experience similar struggles at home, “they get where you’re coming from,” whereas other peers at school who are not experiencing these acculturation issues might not. The Latina staff can also help them navigate these acculturation struggles. One participant said:

They help me understand my mom better. Because here, they specifically try to help Latina girls. So they know the Latina culture. And they understand, like, the family life that you have sometimes. So, like, we get it. And then they start giving advice, which is really cool because not everyone can get it because it’s different.

Several mothers noted that LIP has served as a resource for them. One mother appreciated that LIP staff include her in her daughter’s treatment, where other providers have refused to even confirm that her daughter is a patient. Several other parents noted that LIP has helped them address problems that were not directly related to their daughters’ suicidal behavior. This made the mothers loyal to the program and led them to encourage their daughters to keep attending the program. One mother said that if she has a problem, she can call an LIP staff member “at any time” and they call her back and find out what assistance she needs. This mother said, “they don’t limit themselves to only the children. They help us also.” Another mother said that she had been in an abusive relationship with her own boyfriend, and that what her daughter learned at LIP had helped show her that “Mommy, no, that is not normal.”

LIP helps students succeed academically

Participants noted that assistance with homework and tutoring has helped them improve their schoolwork. One participant said that she used to be failing in school but now has a B+ average, after coming to LIP for the past year. LIP staff members help the participants with high school and college applications (since some New York City high schools have a competitive admissions process). Both participants and parents appreciated that LIP staff will liaison with school officials to resolve conflicts. One mother reported, when her daughter has problems at school, the LIP staff will call the school “or they will go with me” to the school.

LIP staff also provide assistance and strategies to help students address bullying, particularly at school. Participants noted that LIP staff have helped participants avoid bullying situations by meeting with school officials, helping them map out routes in the hallways to avoid bullies, and helping them change classes or even transfer schools in extreme situations. One participant said, “Life is Precious did help me get out of a very tumultuous school environment… and they helped me transfer and feel comfortable in my new school environment.”

LIP helps participants improve peer relationships

Participants said that participating in LIP has helped them build relationships with other girls. One participant said, “We’re all, like, around the same age, so we…understand each other…and we don’t judge each other.” One participant said that she used to be shy but when she made friends at LIP, she learned how to talk to peers, and then she realized she can talk to other students at school just like she talks to peers at LIP. Another girl said that she used to be afraid to leave the house but her family has noticed that by coming to LIP “I’m kind of breaking that, little by little.” Another mother noted that her daughter’s behavior has improved since participating in LIP. She said, her daughter “is more attentive. She is, well, more obedient. She is a little better with the nutrition. She is not wanting to talk like a ‘street person.’ She is speaking more formally. She is more educated and she doesn’t disappear.”

Ongoing Challenges

We also asked participants to describe what they see as challenges that the program continues to face. Participants volunteered relatively little information in this domain. Moreover, the participants generally did not reach a consensus on the types of improvements that they would like to see. Some wanted more activities, especially at one particular site. Some wanted more of a specific type of activity (e.g. exercise, art, or music) but then others would say they wanted less of that activity. While one respondent said that she finds the music program unhelpful, “what if I don’t like to sing? Yeah, I don’t find that really helpful,” another spoke up and said that she likes the music program, “I like piano and guitar and stuff…for me, my opinion, I like doing that.” No consensus emerged for specific activities to add or remove.

Some participants noted that it is difficult when a staff member leaves, as the participant had been building a relationship with a particular staff member, and their case is then transferred to someone else. One participant said, “We understand that they want to further their career. And they can’t be in Life is Precious forever.” Another said, “When they leave the program, they also leave us too.”

Discussion

LIP participants identified several factors that they feel contribute to suicidal behavior among Latina adolescents, and these echo themes that have been identified in previous studies. These themes include negative feelings, including low self-esteem (Goldston et al., 2008); conflicts between parents and adolescents stemming from issues of acculturation, immigration, and gender roles (Zayas et al., 2010; Zayas & Pilat, 2008; Gulbas & Zayas, 2015; Gulbas et al., 2015); struggles in school (Piña-Watson et al., 2014); and struggles with peer relationships (Goldston et al., 2008), including bullying and stigma due to mental health treatment and suicidal behavior.

Respondents shed light on specific ways that LIP has helped to reduce the suicidal risk factors of self-esteem, family conflicts, school and peer conflicts. LIP activities help to improve self-esteem by helping them connect with peers with similar struggles (“I am not alone”). The creative expression therapies (e.g. art, music, and dance) provide an outlet to express their negative emotions, such as by addressing self-harming behaviors (e.g. by writing affirming messages on their arms rather than cutting). The creative expression therapies also help participants to improve self-esteem by enabling them to feel pride in their accomplished product (e.g. painting, song, or performance). LIP helps to address conflicts between parents and adolescents by providing family therapy to promote communication, suggesting specific strategies for conflict resolution (e.g. counting to three before responding in anger; understanding a parent’s point of view if tired or stressed from work), counseling on conflict resolution regarding gender roles, and providing a safe haven where adolescents can temporarily get away from conflicts at home. Additionally, by including the mothers in LIP activities, the mothers and daughters grow in their bond, and the mothers can get assistance for their own needs (e.g. ending domestic violence) that are negatively affecting their daughters. LIP can help with academic struggles by providing access to resources such as computers, tutoring, and assistance with high school and college application processes. The LIP staff can also serve as liaisons with school officials to help combat bullying (e.g. assistance with navigating to a class while avoiding bullies) and arranging for class and school transfers in extreme circumstances. LIP participants also point to the benefits of building peer relationships at LIP, which can in turn result in stronger peer relationships at school. Each of these strategies by LIP has helped to reduce the risk factors that are found to be associated with suicidal behavior in Latina adolescents.

The ongoing challenges (providing program activities that are of interest to all of the participants and managing staff transitions) are likely to be faced by many community-based programs. While the lack of consensus among participants made it difficult to define recommendations for program improvement, it did indicate that participants were comfortable disagreeing with one another within the focus groups.

A few study limitations should be noted. The focus groups were drawn from a voluntary sample of adolescents and mothers who chose to participate. It is possible that people who felt negatively about LIP may have been less likely to attend. It is especially possible that the mothers who made the time and effort to come to LIP on an evening may have felt strongly about the program, or been more engaged with the program. It is also possible that, with many respondents positive about LIP, some may have kept more negative opinions to themselves. However, the moderators attempted to engage all participants in the discussion, frequently checking to see whether there was agreement or disagreement with a statement, and encouraging those who had not yet spoken. All participants spoke at least once during each group, with the exception of one respondent in one group, and none were dominated by any particular participant. The mothers’ focus group was conducted in Spanish and was translated; while it is possible that some nuances were lost in the translation, the translation was professionally certified and reviewed by one of the bilingual focus group moderators. Additionally, it should be noted that LIP operates as a supplement to ongoing mental health treatment. Participants are required to be receiving treatment, but that treatment can occur at any one of a number of local agencies, and the types of treatment and medications may vary widely. We did not assess the types of outpatient treatment that were received by these focus group participants. Moreover, the study was conducted only in three very urban sites in the United States (Bronx, Brooklyn, and Queens) and results may not be generalizable to other locations. The focus groups were only conducted among current LIP participants (and parents) and thus we do not have information on how these findings would compare to a comparison group or the length of time any benefits would continue after LIP participation ends.

Despite these limitations, participants indicate that LIP program has been helpful to them in reducing suicidal behavior. The LIP respondents independently reported risk factors that have also been identified in academic research. Moreover, the respondents provided specific examples of how LIP activities helped to address these risk factors. While the quantitative LIP evaluation results indicate improvements in suicidal behavior and psychological functioning (Humensky, Coronel, Gil, Mazzula, & Lewis-Fernández, 2016), the focus group findings support the hypothesis, illustrated in the Conceptual Framework (Humensky et al., 2013), that the LIP activities are perceived as helping clients to address known risk factors for suicidal behavior. Given the high rates of suicidal behavior among Latina adolescents (CDC, 2015b) and the growing Latino population in the U.S. (Ennis et al., 2001), the need to identify ways to help reduce suicidal behavior constitutes a pressing priority. Due to the fact that most young people are in school, school personnel, including teachers, guidance counselors, and school nurses, interact with youth who are at risk of a number of poor outcomes, including suicidal behavior.

School nurses may be among the first treatment providers sought by adolescents at risk for suicidal behavior. Therefore, school nurses should be aware of risk factors facing Latina adolescents and possible community-based treatment options. While nurses may not have access to the LIP model, they may wish to identify community-based programs that offer some of the components of LIP, such as access to mental health counseling, academic support, and family supportive services. Nurses may also wish to work with existing programs to help address the needs that students have in school. Working collaboratively with adolescents, families, mental health treatment providers, and other school officials may help to address the comprehensive needs faced by adolescents and help reduce the risk of suicidal behaviors.